From the Guidelines
Management of a patient with severe lower quadrant abdominal pain and nausea requires a systematic approach, starting with a thorough assessment and consideration of imaging studies such as abdominal ultrasound or CT scan with contrast to evaluate for appendicitis, diverticulitis, or other conditions, as recommended by the most recent guidelines 1. The patient's presentation with 9/10 lower quadrant pain, no vomiting, some nausea, and a bowel movement 3-4 days ago suggests a possible obstructive or inflammatory process.
- Key considerations in the diagnostic workup include:
- Laboratory tests: complete blood count, comprehensive metabolic panel, urinalysis, and pregnancy test for women of childbearing age
- Imaging studies: abdominal ultrasound or CT scan with contrast to evaluate for appendicitis, diverticulitis, inflammatory bowel disease, ovarian pathology, or urinary tract conditions
- For pain management, consider:
- Intravenous acetaminophen 1000 mg every 6 hours or ketorolac 30 mg IV (if no contraindications)
- Morphine 4-6 mg IV or hydromorphone 0.5-1 mg IV every 4 hours as needed for severe pain
- Address nausea with:
- Ondansetron 4 mg IV every 6 hours or promethazine 12.5-25 mg IV every 6 hours
- Keep the patient NPO (nothing by mouth) until diagnosis is established and administer IV fluids such as normal saline at 100-125 mL/hour to maintain hydration, as suggested by recent studies 1. Surgical consultation should be obtained early if appendicitis, bowel obstruction, or other surgical conditions are suspected, given the high morbidity and mortality associated with delayed diagnosis and treatment 1.
From the Research
Approach to a Patient with Severe Lower Quadrant Abdominal Pain and Nausea
The patient presents with 9/10 lower quadrant pain, no vomiting, some nausea, and a bowel movement 3-4 days ago. The following steps can be taken to manage this patient:
- Evaluate the patient's symptoms and medical history to determine the possible cause of the abdominal pain
- Consider imaging investigations, such as computed tomography (CT), to help define the severity, cause, and complications of the condition 2
- CT can be useful in diagnosing acute small bowel obstruction, acute appendicitis, and other abdominal pathologies 3, 4
- For patients with suspected appendicitis, CT with intravenous contrast can provide high sensitivity and specificity for diagnosis 4
- In pregnant patients with suspected appendicitis, CT can be used to provide an accurate diagnosis and avoid false negative exploratory laparotomy 5
Possible Causes of Lower Quadrant Abdominal Pain
The patient's symptoms could be indicative of several possible causes, including:
- Acute appendicitis
- Acute diverticulitis
- Small bowel obstruction
- Other abdominal pathologies
Diagnostic Imaging
CT can be a useful diagnostic tool in evaluating the patient's condition, particularly in cases where the clinical signs are unclear or the patient has a high risk of complications. The use of CT with contrast enhancement can provide high sensitivity and specificity for diagnosing acute appendicitis 4. However, the choice of imaging modality and contrast enhancement should be based on the patient's individual needs and medical history.
Management of Acute Diverticulitis
For patients with acute diverticulitis, the therapeutic measures aim to put the intestine "at rest" and resolve the infection and inflammation. Antibiotics, such as ampicillin, gentamicin, and metronidazole, can be used to treat the infection, and mesalazine and probiotics may be used to prevent symptomatic recurrence 6.